Extracranial head and neck schwannomas.

Extracranial head and neck schwannomas are usually benign and rarely malignant tumors of peripheral nerve sheath origin. The clinical presentation of these tumors is reviewed in our series of 21 patients, emphasizing the diagnosis with dynamic infused CT scans. Management is suggested and outcome analysis is provided.     

Current management of head and neck schwannomas

PURPOSE OF REVIEW: The purpose of this review is to discuss the contemporary management of head and neck schwannomas by reviewing the literature and presenting the authors' experience. RECENT FINDINGS: Molecular studies are attempting to link genetic factors to the development of nerve sheath tumors. Many studies emphasize the importance of preserving the nerve of origin, but structural preservation may not necessarily lead to the preservation of its functional integrity. The importance of neural reconstruction and postoperative rehabilitation is also emphasized. SUMMARY: Head and neck schwannomas are uncommon tumors that may affect any peripheral, cranial, or autonomic nerve. This explains their variation in terms of location, clinical presentation, and outcome after surgical resection. History, physical examination, fine needle aspiration, and magnetic resonance imaging are used as diagnostic modalities. Cure entails a complete resection, all attempts being made to preserve the nerve of origin. Otherwise, immediate reconstruction and postoperative rehabilitation should be undertaken in the context of a multidisciplinary management team.     

Non-vestibular head and neck schwannomas: a 10-year experience

Schwannomas are rare and slow growing tumours, arising from Schwann cells which provide myelin; less than 1 % of them degenerate into a malignant state. Although most studies are based on acoustic schwannomas, the majority of these tumours are non-vestibular and extracranial. Up to 45 % of them can be localised in head and neck districts, where they represent a diagnostic challenge because they are in differential diagnosis with lipoma, brachial cyst, paraganglioma and adenopathy. Between February 2002 and September 2012 our experience considers 18 patients affected by schwannomas localised in the neck in 14 cases, in the oral cavity in 2 cases, in the upper lip in 1 case and finally in the nose in 1 case. A painless neck mass was the major symptom referred, as well as dysphonia and oral pain. Ultrasound scan with fine needle aspiration biopsy was done in half of the group and was diagnostic in 30 %, whereas magnetic resonance imaging was diagnostic in 77 %, confirming its primary role in diagnostic work-up. The surgical approach was mainly by cervical incision and the intraneural extracapsular enucleation was the technique used without nerve injury in 89 % of cases. Follow-up period was 6–120 months and no evidence of relapse was registered.     

Primary extracranial meningiomas of the head and neck

Extracranial meningiomas comprise approximately 2% of all meningiomas. Primary extracranial meningiomas are even less common. This report details our experience with these unusual tumors from 1972 to 1989. The diagnosis, surgical management, and significant histopathologic features are discussed. The correlation of primary extracranial meningiomas with neurofibromatosis type II and a treatment algorithm are presented.     

Extracranial head and neck schwannomas: a clinical analysis of 33 patients

OBJECTIVE: To study the clinical features, diagnosis, and management of the extracranial head and neck schwannomas. STUDY DESIGN: Retrospective study. METHODS: The clinical data of 33 patients with schwannoma of the head and neck from 1996 to 2006 were studied retrospectively. RESULTS: Extracranial head and neck schwannomas usually presented as solitary and well-demarcated lesions with insidious course. Although benign, the lesion can cause secondary symptoms, such as nasal obstruction, dysphasia, and hoarseness, relevant to location of the lesion. Fine needle aspiration cytology, computed tomography scans, and magnetic resonance imaging may provide limited implications in the diagnosis of schwannomas, whereas postoperative pathologic examination establishes the final diagnosis. CONCLUSIONS: Complete surgical excisions with appropriate approaches have proven to be efficient and successful in the treatment of head and neck schwannomas.     

Extracranial head and neck schwannomas: a review of 8 years experience

Schwannomas of the head and neck are uncommon tumors that arise from cranial, peripheral or autonomic nerves. In this study we review a series of 52 cases of schwannoma originating in the head and neck region over an 8-year period. All the tumors were benign, with the exception of one malignant schwannoma. The age range of the patients studied was 13-76 years and there was a predilection for males. Twenty-five schwannomas occurred in the scalp, face and external ear canal, 9 in the oral or nasal cavity and 18 in the neck. Seven cases of neck schwannoma originating from the major nerve system were found in the parapharyngeal space, all of which were located in the post-styloid compartment. Cervical plexus schwannomas originated either in the peripheral nerves or in an unidentified area of the nervous system; seven tumors were found in the posterior triangle of the neck and two in the anterior triangle. Two of the tumors originating in the brachial plexus were located in the posterior neck and one in the anterior neck. Tumors originating in the vagus nerve or sympathetic chain were all located in the anterior triangle of the neck.     

Extracranial head and neck schwannomas: a study of the nerve of origin

Schwannoma is a type of benign nerve sheath tumour arising from the Schwann cell. Because of the close relationship between the tumour and the nerve of origin (NOO), the operation of extracranial head and neck schwannoma may lead to palsy of major nerve. For this reason, an accurate diagnosis of schwannoma with the identification of the NOO is crucial to the management. The aim of this review was to find out the distribution of the NOO and the usefulness of the investigations in the diagnosis of schwannoma. Medical records of the patients who underwent operation of the extracranial head and neck schwannoma in our division were reviewed. Between January 2000 and December 2009, 30 cases of extracranial head and neck schwannoma were operated. Sympathetic trunk (10, 33%) and vagus nerve (6, 20%) were the two most common NOOs. In five (17%) cases, the NOO was not found to be arising from any major nerve. For these 30 patients, 20 received fine needle aspiration cytology (FNAC) and 26 underwent imaging studies (computed tomography or magnetic resonance imaging) before operation. The specificity of FNAC and imaging studies in making the diagnosis of schwannoma was 20 and 38%, respectively. For the patients who had nerve palsies on presentation, their deficits remained after operation. The rate of nerve palsy after tumour excision with division of NOO and intracapsular enucleation was 100 and 67%, respectively. The diagnosis of schwannoma is suggested by clinical features and supported by investigations. Most of the time, the diagnosis can only be confirmed on the histological study of the surgical specimen. Sympathetic trunk and vagus nerve are the two common NOOs. MRI is the investigation of choice in the diagnosis of schwannoma and the identification of NOO.     

Management of extracranial arteriovenous malformations of the head and neck

The purpose of this study was to review the outcomes of the different therapies for extracranial head and neck arteriovenous malformations (AVMs).AVMs are high-flow congenital vascular anomalies. They are composed of a complex system of vessels directly connecting feeding arteries to draining veins forming a nidus.They may be potentially life-threatening due to progressive symptoms and infiltrative disease. Extracranial AVMs most commonly affect the head and neck area (47.4%) followed by the extremities (28.5%). AVMs are best characterized as being either focal or diffuse. Focal AVMs have good outcomes following adequate treatment. Diffuse lesions have multiple feeding vessel, which results in high rates of recurrence despite treatment.The management of AVMs includes conventional surgery and endovascular techniques. A combination of embolization and surgical resection has become the treatment of choice over the last years. The main goal of both forms of treatment being the complete blockage or resection of the nidus. Transcatheter embolization of vessels has evolved over the years and new embolic agents have emerged. The types of materials available for embolization are classified into mechanical devices, liquid agents and particulates. Efficacy, rate of recurrence and most common complications were evaluated.AVMs recurrence after embolization or resection is reported in up to 80% of cases. Incomplete resection and embolization can induce aggressive growth of the remaining nidus and the risk of progression is up to 50% within the first 5 years and recurrences can occur up to 10 years later.Although ethanol seems to be associated with the highest degree of cure and permanent occlusion, the overall complication rate reported was 48%. Other materials, such as cyanoacrylate, have obtained modest rates of complete remission, while the reported rates of complete regression of AVMs with Fibrin glue and Polyvinyl alcohol are above 50%. At present, there are no unified agreement on the ideal embolic agent.Therefore, a multidisciplinary approach is recommended to support decision making about the best therapeutic approach and to achieve optimal outcome. A long-term post-treatment follow-up is recommended to recognize early recurrence.     

Treatment for extracranial arteriovenous malformations of the head and neck

CONCLUSIONS: For extracranial arteriovenous malformations of the head and neck (HNAVMs), in which the nidus was accessible via the percutaneous route, ethanol sclerotherapy was a feasible and safe first-line treatment, although successful outcomes were obtained for only about half of the subjects. For other HNAVMs, surgical excision with embolization may be the best choice of treatment. OBJECTIVE: To suggest a treatment protocol for patients with HNAVMs by comparing the treatment outcomes and complications of ethanol sclerotherapy with those of surgical excision combined with embolization. MATERIAL AND METHODS: Twenty patients who had been diagnosed with HNAVM and treated between 1995 and 2002 were retrospectively reviewed. Ethanol sclerotherapy, surgical excision and embolization were used as treatments, either alone or in various combinations. The treatment outcomes and complications with the different modalities were analyzed. RESULTS: Ethanol sclerotherapy was used for 12 cases, with a success rate of 50.0% and a permanent complication rate of 8.3%. Surgical excision combined with embolization was used for 13 patients. Although all patients achieved successful resolution of their HNAVM after surgical excision, 15.4% suffered from permanent complications. In total, 16/20 patients (80.0%) eventually achieved a > or = 75% reduction in the size of their lesions.     

Treatment for extracranial arteriovenous malformations of the head and neck

Conclusions. For extracranial arteriovenous malformations of the head and neck (HNAVMs), in which the nidus was accessible via the percutaneous route, ethanol sclerotherapy was a feasible and safe first-line treatment, although successful outcomes were obtained for only about half of the subjects. For other HNAVMs, surgical excision with embolization may be the best choice of treatment. Objective. To suggest a treatment protocol for patients with HNAVMs by comparing the treatment outcomes and complications of ethanol sclerotherapy with those of surgical excision combined with embolization. Material and methods. Twenty patients who had been diagnosed with HNAVM and treated between 1995 and 2002 were retrospectively reviewed. Ethanol sclerotherapy, surgical excision and embolization were used as treatments, either alone or in various combinations. The treatment outcomes and complications with the different modalities were analyzed. Results. Ethanol sclerotherapy was used for 12 cases, with a success rate of 50.0% and a permanent complication rate of 8.3%. Surgical excision combined with embolization was used for 13 patients. Although all patients achieved successful resolution of their HNAVM after surgical excision, 15.4% suffered from permanent complications. In total, 16/20 patients (80.0%) eventually achieved a ≥75% reduction in the size of their lesions.     

Streptococcus milleri head and neck abscesses: a case series

Streptococcus milleri infections and abscesses in the head and neck region have been previously reported, but there is still a dearth of clinical literature on this topic. To add to the available reports and to promote a better understanding and awareness of this clinically important entity, we present this retrospective review of 7 cases of head and neck abscess caused by S milleri infection. We have placed particular emphasis on antibiotic sensitivity patterns. These patients-6 men and 1 woman, aged 28 to 73 years (mean: 42.7)-had been seen at a district general hospital in Gosford, Australia, over a 6-month period. All patients had undergone surgical intervention and had been treated with intravenous antibiotics. All the S milleri cultures were sensitive to penicillin G, cephalexin, and erythromycin. Six of these patients experienced a resolution of their abscess, while 1 patient died from overwhelming sepsis. We believe that the initiation of penicillin G, cephalexin, or erythromycin is a good starting point for empiric therapy. S milleri should be considered as a causative organism in a patient who presents with a head and neck abscess, especially in the presence of a dental infection. Such a patient should be monitored closely for airway obstruction and distal infective sequelae. Also in this article, we compare our findings with those reported in two other published series.     

Malignant fibrous histiocytoma of the head and neck: a case series

Purpose

The study objective is to evaluate the clinical features and outcomes of patients treated for head and neck malignant fibrous histiocytoma at a tertiary care medical facility.

Materials and methods

This is a retrospective case series of 17 adult subjects with malignant fibrous histiocytoma of the head and neck who were treated between January 1, 1965, and December 31, 2010. This study was conducted using patient charts at a tertiary medical center. Subject selection was conducted using Current Procedural Terminology numbers; International Classification of Diseases, Ninth Revision, codes; and a search of the tumor registry.

Results

Chart review of the 17 identified subjects revealed an overwhelming male predominance (88%) with an overall mean age of 69 years(52–87 years). Thirteen patients (78%) underwent some form of surgical resection, 6 patients (35%) received radiation therapy, and 6 (35%) were given chemotherapy over the course of treatment. Nine tumors (53%) had a cutaneous origin, whereas 8 lesions (47.1%) were found in the soft tissue of the head and neck region. The local recurrence rate following a single resection was 46%. Overall median survival following diagnosis was found to be 65 months, with a 5-year survival rate of 52%. Median disease-free survival was 20 months, with a 5-year disease-free survival rate of 37%. Overall median and 5-year survival rates were found to increase with clear surgical margins, as was 5-year survival.

Conclusions

Aggressive surgical management to achieve clear margins is central to the effective treatment of malignant fibrous histiocytoma of the head and neck. Metastatic disease portends a dismal prognosis.     

Autoimmune thrombocytopenic purpura-like syndrome in a patient with head and neck cancer

We report a case of presumed autoimmune thrombocytopenic purpura in a patient with squamous cell carcinoma of the neck. A review of the literature on the association of autoimmune thrombocytopenic purpura and solid tumors is presented. Autoimmune-like thrombocytopenia should be considered when patients with head and neck carcinoma present with an acute hemorrhagic diathesis.     

Rhabdomyolysis in the patient undergoing head and neck surgery

Rhabdomyolysis is increasingly recognized as a cause of acute renal failure. Though often the result of extensive trauma, rhabdomyolysis may also appear in the postoperative period. We describe three recent cases in patients undergoing head and neck surgery. Early diagnosis is based on laboratory and clinical examination. Treatment aimed at renal hyperperfusion with hydration and diuretics may prevent nephrotoxic reaction.